Provider Demographics
NPI:1649298415
Name:SPINE ARTS CENTER
Entity type:Organization
Organization Name:SPINE ARTS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARRY
Authorized Official - Middle Name:T
Authorized Official - Last Name:KRAKOS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:703-644-2222
Mailing Address - Street 1:6120 BRANDON AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-2522
Mailing Address - Country:US
Mailing Address - Phone:703-644-2222
Mailing Address - Fax:703-644-2488
Practice Address - Street 1:6120 BRANDON AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-2522
Practice Address - Country:US
Practice Address - Phone:703-644-2222
Practice Address - Fax:703-644-2488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104555563111N00000X
VA0104001821111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA=========OtherTAX ID
VA=========OtherTAX ID